405800577-7-14-2023-29-AS-KBUY-CU6PJE-20230728112126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:23:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230710114951

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 66	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Kirk Klotthor, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility exposes residents to hazardous facility grounds conditions

INVESTIGATION FINDINGS:

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On 7/14/23 at 10:43 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced 10-day complaint visit to the facility listed above. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit.

On the allegation, “Facility exposes residents to hazardous facility grounds conditions,” the complainant was concerned that the areas along the sidewalks in the garden accessible to residents have holes with wires and water in them and has the potential for residents to stumble and get injured. To investigate, LPA toured the facility and interviewed the administrator.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230710114951

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 07/14/2023

NARRATIVE

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On 7/14/23 at 10: 50 am, LPA interviewed the administrator. The administrator states there was a plumbing leak in the garden and that a board was placed over a hole approximately 4 days ago. On 7/14/23, LPA toured the garden and observed a board in the flower bed covering the irrigation pipes. LPA walked on the board, sized approximately 2 feet x 2 feet, and walked on the soil to the right of it, approximately 4 feet long, and both were secure. There was no indication of the possibility of the board or surrounding area may collapse.

Based on the evidence obtained, the allegation, “Facility exposes residents to hazardous facility grounds conditions,” is deemed Unsubstantiated at this time.

Exit interview conducted, report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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